Publications
262 results found
Skovdal M, Magutshwa-Zitha S, Campbell C, et al., 2017, Getting off on the wrong foot? How community groups in Zimbabwe position themselves for partnerships with external agencies in the HIV response, Globalization and Health, Vol: 13, ISSN: 1744-8603
BackgroundPartnerships are core to global public health responses. The HIV field embraces partnership working, with growing attention given to the benefits of involving community groups in the HIV response. However, little has been done to unpack the social psychological foundation of partnership working between well-resourced organisations and community groups, and how community representations of partnerships and power asymmetries shape the formation of partnerships for global health. We draw on a psychosocial theory of partnerships to examine community group members’ understanding of self and other as they position themselves for partnerships with non-governmental organisations.MethodsThis mixed qualitative methods study was conducted in the Matobo district of Matabeleland South province in Zimbabwe. The study draws on the perspectives of 90 community group members (29 men and 61 women) who participated in a total of 19 individual in-depth interviews and 9 focus group discussions (n = 71). The participants represented an array of different community groups and different levels of experience of working with NGOs. Verbatim transcripts were imported into Atlas.Ti for thematic indexing and analysis.ResultsGroup members felt they played a central role in the HIV response. Accepting there is a limit to what they can do in isolation, they actively sought to position themselves as potential partners for NGOs. Partnerships with NGOs were said to enable community groups to respond more effectively as well as boost their motivation and morale. However, group members were also acutely aware of how they should act and perform if they were to qualify for a partnership. They spoke about how they had to adopt various strategies to become attractive partners and ‘supportable’ – including being active and obedient.ConclusionsMany community groups in Zimbabwe recognise their role in the HIV response and actively navigate representational systems of self and
Mangal TD, UNAIDS Working Group on CD4 Progression and Mortality Amongst HIV Seroconverters including the CASCADE Collaboration in EuroCoord, 2017, Joint estimation of CD4+ cell progression and survival in untreated individuals with HIV-1 infection., AIDS, Vol: 31, Pages: 1073-1082, ISSN: 0269-9370
OBJECTIVE: We compiled the largest dataset of seroconverter cohorts to date from 25 countries across Africa, North America, Europe, and Southeast/East (SE/E) Asia to simultaneously estimate transition rates between CD4 cell stages and death, in antiretroviral therapy (ART)-naive HIV-1-infected individuals. DESIGN: A hidden Markov model incorporating a misclassification matrix was used to represent natural short-term fluctuations and measurement errors in CD4 cell counts. Covariates were included to estimate the transition rates and survival probabilities for each subgroup. RESULTS: The median follow-up time for 16 373 eligible individuals was 4.1 years (interquartile range 1.7-7.1), and the mean age at seroconversion was 31.1 years (SD 8.8). A total of 14 525 individuals had recorded CD4 cell counts pre-ART, 1885 died, and 6947 initiated ART. Median (interquartile range) survival for men aged 20 years at seroconversion was 13.0 (12.4-13.4), 11.6 (10.9-12.3), and 8.3 years (7.9-8.9) in Europe/North America, Africa, and SE/E Asia, respectively. Mortality rates increase with age (hazard ratio 2.22, 95% confidence interval 1.84-2.67 for >45 years compared with <25 years) and vary by region (hazard ratio 2.68, 1.75-4.12 for Africa and 1.88, 1.50-2.35 for Asia compared with Europe/North America). CD4 cell decline was significantly faster in Asian cohorts compared with Europe/North America (hazard ratio 1.45, 1.36-1.54). CONCLUSION: Mortality and CD4 cell progression rates exhibited regional and age-specific differences, with decreased survival in African and SE/E Asian cohorts compared with Europe/North America and in older age groups. This extensive dataset reveals heterogeneities between regions and ages, which should be incorporated into future HIV models.
Eaton JW, Johnson CC, Gregson S, 2017, The cost of not re-testing: HIV misdiagnosis in the ART ‘test-and-offer’ era, Clinical Infectious Diseases, Vol: 65, Pages: 522-525, ISSN: 1537-6591
We compared estimated costs of retesting human immunodeficiency virus (HIV)-positive persons before antiretroviral therapy (ART) initiation to the costs of ART provision to misdiagnosed HIV-negative persons. Savings from averted unnecessary ART costs were greater than retesting costs within 1 year using assumptions representative of HIV testing performance in programmatic settings. Countries should implement re-testing before ART initiation.
Wilson KC, Mhangara M, Dzangare J, et al., 2017, Does nonlocal women's attendance at antenatal clinics distort HIV prevalence surveillance estimates in pregnant women in Zimbabwe?, AIDS, Vol: 31, Pages: S95-S102, ISSN: 0269-9370
Objective: The objective was to assess whether HIV prevalence measured among women attending antenatal clinics (ANCs) are representative of prevalence in the local area, or whether estimates may be biased by some women's choice to attend ANCs away from their residential location. We tested the hypothesis that HIV prevalence in towns and periurban areas is underestimated in ANC sentinel surveillance data in Zimbabwe.Methods: National unlinked anonymous HIV surveillance was conducted at 19 ANCs in Zimbabwe in 2000, 2001, 2002, 2004, 2006, 2009, and 2012. This data was used to compare HIV prevalence and nonlocal attendance levels at ANCs at city, town, periurban, and rural clinics in aggregate and also for individual ANCs.Results: In 2000, HIV prevalence at town ANCs (36.6%, 95% CI 34.4–38.9%) slightly underestimated prevalence among urban women attending these clinics (40.7%, 95% CI 37.6–43.9%). However, there was no distortion in HIV prevalence at either the aggregate clinic location or at individual clinics in more recent surveillance rounds. HIV prevalence was consistently higher in towns and periurban areas than in rural areas. Nonlocal attendance was high at town (26–39%) and periurban (53–95%) ANCs but low at city clinics (<10%). However, rural women attending ANCs in towns and periurban areas had higher HIV prevalence than rural women attending rural clinics, and were younger, more likely to be single, and less likely to be housewives.Conclusions: : In Zimbabwe, HIV prevalence among ANC attendees provides reliable estimates of HIV prevalence in pregnant women in the local area.
Silhol R, Gregson S, Nyamukapa C, et al., 2017, Empirical validation of the UNAIDS Spectrum model for subnational HIV estimates: case-study of children and adults in Manicaland, Zimbabwe, AIDS, Vol: 31, Pages: S41-S50, ISSN: 0269-9370
Background: More cost-effective HIV control may be achieved by targeting geographical areas with high infection rates. The AIDS Impact model of Spectrum – used routinely to produce national HIV estimates – could provide the required subnational estimates but is rarely validated with empirical data, even at a national level.Design: The validity of the Spectrum model estimates were compared to empirical estimates.Methods: Antenatal surveillance and population survey data from a population HIV cohort study in Manicaland, east Zimbabwe, were input into Spectrum 5.441 to create a simulation representative of the cohort population. Model and empirical estimates were compared for key demographic and epidemiological outcomes. Alternative scenarios for data availability were examined and sensitivity analyses were conducted for model assumptions considered important for subnational estimates.Results: Spectrum estimates generally agreed with observed data but HIV incidence estimates were higher than empirical estimates while estimates of early age all-cause adult mortality were lower. Child HIV prevalence estimates matched well with the survey prevalence among children. Estimated paternal orphanhood was lower than empirical estimates. Including observations from earlier in the epidemic did not improve the HIV incidence model fit. Migration had little effect on observed discrepancies - possibly because the model ignores differences in HIV prevalence between migrants and residents.Conclusions: The Spectrum model, using subnational surveillance and population data, provided reasonable subnational estimates although some discrepancies were noted. Differences in HIV prevalence between migrants and residents may need to be captured in the model if applied to subnational epidemics.
Case KK, Gregson S, Mahy M, et al., 2017, Editorial: methodological developments in the Joint United Nations Programme on HIV/AIDS estimates, AIDS, Vol: 31, Pages: S1-S4, ISSN: 0269-9370
The Joint United Nations Programme on HIV/AIDS (UNAIDS) publishes estimates of the HIV epidemic every year [1]. For 2016, estimates are available for 160 countries representing 98% of the global population. These estimates are produced by countries with guidance from UNAIDS. The methods used in this process continue to evolve over time under the stewardship of the UNAIDS Reference Group on Estimates, Modelling and Projections [2].In 2014, the WHO convened the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) Working Group with the aim to define and promote good practice in reporting global health estimates [3]. The GATHER Statement is the outcome produced by this group. It defines a list of reporting requirements to allow for the accurate interpretation, and facilitate the appropriate use, of global health estimates [4]. UNAIDS fully endorses and supports the GATHER Statement.The current special supplement, which details the methods used to produce the 2016 UNAIDS estimates, further supports the routine publication of data sources and methods used as part of an open and transparent process. It provides updates of the evolving understanding of the data on which the estimates are based, the methods used to derive the estimates, justification of changes in these methods, and the sources of new data available to inform these modifications. It follows a series of such collections [5–10] which have documented and described the evolving methods used to produce the UNAIDS Global AIDS estimates since 2004.
Sheng B, Marsh K, Slavkovic AB, et al., 2017, Statistical models for incorporating data from routine HIV testing of pregnant women at antenatal clinics into HIV/AIDS epidemic estimates, AIDS, Vol: 31, Pages: S87-S94, ISSN: 0269-9370
Objective: HIV prevalence data collected from routine HIV testing of pregnant women at antenatal clinics (ANC-RT) are potentially available from all facilities that offer testing services to pregnant women and can be used to improve estimates of national and subnational HIV prevalence trends. We develop methods to incorporate these new data source into the Joint United Nations Programme on AIDS Estimation and Projection Package in Spectrum 2017.Methods: We develop a new statistical model for incorporating ANC-RT HIV prevalence data, aggregated either to the health facility level (site-level) or regionally (census-level), to estimate HIV prevalence alongside existing sources of HIV prevalence data from ANC unlinked anonymous testing (ANC-UAT) and household-based national population surveys. Synthetic data are generated to understand how the availability of ANC-RT data affects the accuracy of various parameter estimates.Results: We estimate HIV prevalence and additional parameters using both ANC-RT and other existing data. Fitting HIV prevalence using synthetic data generally gives precise estimates of the underlying trend and other parameters. More years of ANC-RT data should improve prevalence estimates. More ANC-RT sites and continuation with existing ANC-UAT sites may improve the estimate of calibration between ANC-UAT and ANC-RT sites.Conclusion: We have proposed methods to incorporate ANC-RT data into Spectrum to obtain more precise estimates of prevalence and other measures of the epidemic. Many assumptions about the accuracy, consistency, and representativeness of ANC-RT prevalence underlie the use of these data for monitoring HIV epidemic trends and should be tested as more data become available from national ANC-RT programs.
Schaefer R, Gregson S, Takaruza A, et al., 2017, Spatial patterns of HIV prevalence and Service Use in East Zimbabwe: implications for future targeting of interventions, Journal of the International AIDS Society, Vol: 20, ISSN: 1758-2652
Introduction: Focusing resources for HIV control on geographic areas of greatest need in countries with generalised epidemics has been recommended to increase cost-effectiveness. However, socio-economic inequalities between areas of high and low prevalence could raise equity concerns and have been largely overlooked. We describe spatial patterns in HIV prevalence in east Zimbabwe and test for inequalities in accessibility and uptake of HIV services prior to the introduction of spatially-targeted programmes.Methods: 8092 participants in an open-cohort study were geo-located to 110 locations. HIV prevalence and HIV testing and counselling (HTC) uptake were mapped with ordinary kriging. Clusters of high or low HIV prevalence were detected with Kulldorff statistics, and the socio-economic characteristics and sexual risk behaviours of their populations, and levels of local HIV service availability (measured in travel distance) and uptake were compared. Kulldorff statistics were also determined for HTC, antiretroviral therapy (ART), and voluntary medical male circumcision (VMMC) uptake.Results: One large and one small high HIV prevalence cluster (relative risk [RR]=1.78, 95% confidence interval [CI]=1.53–2.07; RR=2.50, 95% CI=2.08–3.01) and one low-prevalence cluster (RR=0.70, 95% CI=0.60–0.82) were detected. The larger high-prevalence cluster was urban with a wealthier population and more high-risk sexual behaviour than outside the cluster. Despite better access to HIV services, there was lower HTC uptake in the high-prevalence cluster (odds ratio [OR] of HTC in past 3 years: OR=0.80, 95% CI=0.66–0.97). The low-prevalence cluster was predominantly rural with a poorer population and longer travel distances to HIV services; however, uptake of HIV services was not reduced.Conclusions: High-prevalence clusters can be identified to which HIV control resources could be targeted. To date, poorer access to HIV services in the poorer low-prevalence areas h
Elmes JAR, Skovdal M, Nhongo K, et al., 2017, A reconfiguration of the sex trade: How social and structural changes in eastern Zimbabwe left women involved in sex work and transactional sex more vulnerable, PLOS One, Vol: 12, ISSN: 1932-6203
Understanding the dynamic nature of sex work is important for explaining the course of HIV epidemics. While health and development interventions targeting sex workers may alter the dynamics of the sex trade in particular localities, little has been done to explore how large-scale social and structural changes, such as economic recessions–outside of the bounds of organizational intervention–may reconfigure social norms and attitudes with regards to sex work. Zimbabwe’s economic collapse in 2009, following a period (2000–2009) of economic decline, within a declining HIV epidemic, provides a unique opportunity to study community perceptions of the impact of socio-economic upheaval on the sex trade. We conducted focus group discussions with 122 community members in rural eastern Zimbabwe in January-February 2009. Groups were homogeneous by gender and occupation and included female sex workers, married women, and men who frequented bars. The focus groups elicited discussion around changes (comparing contemporaneous circumstances in 2009 to their memories of circumstances in 2000) in the demand for, and supply of, paid sex, and how sex workers and clients adapted to these changes, and with what implications for their health and well-being. Transcripts were thematically analyzed. The analysis revealed how changing economic conditions, combined with an increased awareness and fear of HIV–changing norms and local attitudes toward sex work–had altered the demand for commercial sex. In response, sex work dispersed from the bars into the wider community, requiring female sex workers to employ different tactics to attract clients. Hyperinflation meant that sex workers had to accept new forms of payment, including sex-on-credit and commodities. Further impacting the demand for commercial sex work was a poverty-driven increase in transactional sex. The economic upheaval in Zimbabwe effectively reorganized the market for sex by reducing previousl
Melegaro A, Del Fava E, Poletti P, et al., 2017, Social contact structures and time use patterns in the Manicaland Province of Zimbabwe., PLOS One, Vol: 12, ISSN: 1932-6203
BACKGROUND: Patterns of person-to-person contacts relevant for infectious diseases transmission are still poorly quantified in Sub-Saharan Africa (SSA), where socio-demographic structures and behavioral attitudes are expected to be different from those of more developed countries. METHODS AND FINDINGS: We conducted a diary-based survey on daily contacts and time-use of individuals of different ages in one rural and one peri-urban site of Manicaland, Zimbabwe. A total of 2,490 diaries were collected and used to derive age-structured contact matrices, to analyze time spent by individuals in different settings, and to identify the key determinants of individuals' mixing patterns. Overall 10.8 contacts per person/day were reported, with a significant difference between the peri-urban and the rural site (11.6 versus 10.2). A strong age-assortativeness characterized contacts of school-aged children, whereas the high proportion of extended families and the young population age-structure led to a significant intergenerational mixing at older ages. Individuals spent on average 67% of daytime at home, 2% at work, and 9% at school. Active participation in school and work resulted the key drivers of the number of contacts and, similarly, household size, class size, and time spent at work influenced the number of home, school, and work contacts, respectively. We found that the heterogeneous nature of home contacts is critical for an epidemic transmission chain. In particular, our results suggest that, during the initial phase of an epidemic, about 50% of infections are expected to occur among individuals younger than 12 years and less than 20% among individuals older than 35 years. CONCLUSIONS: With the current work, we have gathered data and information on the ways through which individuals in SSA interact, and on the factors that mostly facilitate this interaction. Monitoring these processes is critical to realistically predict the effects of interventions on infectious diseas
Rhead RD, Masimirembwa C, Cooke G, et al., 2016, Might ART adherence estimates be improved by combining biomarker and self-report data?, PLOS One, Vol: 11, ISSN: 1932-6203
BackgroundAs we endeavour to examine rates of viral suppression in PLHIV, reliable data on ART adherence are needed to distinguish between the respective contributions of poor adherence and treatment failure on high viral load. Self-reported data are susceptible to response bias and although biomarker data on drug presence and concentration can provide a superior, alternative method of measurement, complications due to drug-drug interactions and genetic variations can cause some inaccuracies. We investigate the feasibility of combining both biomarker and self-report data to produce a potentially more accurate measure of ART adherence.MethodsData were taken from a large general-population survey in the Manicaland province, Zimbabwe, conducted in 2009–2011. HIV-infected adults who had initiated ART (N = 560) provided self-report data on adherence and dried blood spot samples that were analysed for traces of ART medication. A new three-category measure of ART adherence was constructed, based on biomarker data but using self-report data to adjust for cases with abnormally low and high drug concentrations due to possible drug-drug interactions and genetic factors, and was assessed for plausibility using survey data on socio-demographic correlates.Results94.3% (528/560) and 92.7% (519/560) of the sample reported faithful adherence to their medication and had traces of ART medication, respectively. The combined measure estimated good evidence of ART adherence at 69% and excellent evidence of adherence at 53%. The regression analysis results showed plausible patterns of ART adherence by socio-demographic status with men and younger participants being more likely to adhere poorly to medication, and higher socio-economic status individuals and those living in more urban locations being more likely to adhere well.ConclusionBiomarker and self-reported measures of adherence can be combined in a meaningful way to produce a potentially more accurate measure of ART adherence.
Negin J, Gregson S, Eaton JW, et al., 2016, Rising levels of HIV infection in older adults in eastern Zimbabwe, PLOS One, Vol: 11, ISSN: 1932-6203
BackgroundWith the scale-up of antiretroviral treatment across Africa, many people are living longer with HIV. Understanding the ageing of the HIV cohort and sexual behaviour among older adults are important for appropriately responding to the changing demographics of people living with HIV.MethodsWe used data from a large population-based open cohort in eastern Zimbabwe to examine HIV prevalence trends and incidence among those aged 45 years and older. Five survey rounds have been completed between 1998 and 2011. Incidence was analysed using midpoint between last negative and first positive HIV test.ResultsAcross the survey rounds, 13,071 individuals were followed for 57,676 person years. While HIV prevalence among people aged 15–44 has fallen across the five rounds, HIV prevalence among those aged 45–54 has increased since the 2006–08 survey round. In the 2009–11 round, HIV prevalence among men aged 45–54 was 23.4% compared to 11.0% among those aged 15–44. HIV positive people aged 45–54 now represent more than 20% of all those living with HIV in Manicaland. Among those aged 45 years and older, there were 85 seroconversions in 11,999 person years for an HIV incidence of 0.708 per 100 person years. Analysis of cohort data and assessment of behavioural risk factors for HIV infection among older people shows significantly lower levels of condom use among older adults and a number of seroconversions past the age of 50.ConclusionsThe cohort of people living with HIV is ageing in Zimbabwe and the behaviour of older adults puts them at risk of HIV infection. Older adults must be included in both HIV prevention and treatment programs.
Garnett G, Hallett T, Gregson S, 2016, HIV Prevention Cascades: Identifying Gaps in the Delivery of HIV Prevention Interventions, Conference on HIV Research for Prevention (HIV R4P), Publisher: Mary Ann Liebert, Pages: 245-245, ISSN: 0889-2229
Marston M, Nakiyingi-Miiro J, Kusemererwa S, et al., 2016, The effects of HIV on fertility by infection duration: evidence from African population cohorts before ART availability: Fertility by duration of HIV infection, AIDS, Vol: 31, Pages: S69-S76, ISSN: 1473-5571
OBJECTIVES: To estimate the relationship between HIV natural history and fertility by duration of infection in East and Southern Africa before the availability of antiretroviral therapy, and assess potential biases in estimates of age-specific sub-fertility when using retrospective birth histories in cross-sectional studies. DESIGN: Pooled analysis of prospective population-based HIV cohort studies in Masaka (Uganda) Kisesa (Tanzania), and Manicaland (Zimbabwe). METHODS: Women aged 15-49 who had ever tested for HIV were included. Analyses were censored at antiretroviral treatment roll out. Fertility rate ratios were calculated to see the relationship of duration of HIV infection on fertility, adjusting for background characteristics. Survivorship and misclassification biases on age-specific subfertility estimates from cross-sectional surveys were estimated by reclassifying person time from the cohort data to simulate cross-sectional surveys and comparing fertility rate ratios to true cohort results. RESULTS: HIV negative and positive women contributed 15,440 births and 86320 person years; and 1,236 births and 11240 thousand person years respectively to the final dataset. Adjusting for age, study site and calendar year, each additional year since HIV sero conversion was associated with a 0.02 (95%CI 0.01-0.03) relative decrease infertility for HIV-positive women. Survivorship and misclassification biases in simulated retrospective birth histories resulted in modest underestimates of sub-fertility by 2-5% for age groups 20-39y. CONCLUSION: Longer duration of infection is associated with greater relative fertility reduction for HIV-positive women. This should be considered when creating estimates for HIV prevalence among pregnant women and PMTCT need over the course of the HIV epidemic and ART scale-up.
Del Fava E, Piccarreta R, Gregson S, et al., 2016, Transition to parenthood and HIV infection in rural Zimbabwe, PLOS One, Vol: 11, ISSN: 1932-6203
BackgroundThe relationship between the risk of acquiring human immunodeficiency virus (HIV) infection and people’s choices about life course events describing the transition to parenthood–sexual debut, union (in the form of marriage, cohabitation, or long-term relationship), and parenthood–is still unclear. A crucial role in shaping this relationship may be played by the sequence of these events and by their timing. This suggests the opportunity to focus on the life courses in their entirety rather than on the specific events, thus adopting a holistic approach that regards each individual’s life course trajectory as a whole.MethodsWe summarise the individual life courses describing the transition to parenthood using ordered sequences of the three considered events. We aim to (i) investigate the association between the sequences and HIV infection, and (ii) understand how these sequences interact with known mechanisms for HIV transmission, such as the length of sexual exposure and the experience of non-regular sexual partnerships. For this purpose, we use data from a general population cohort study run in Manicaland (Zimbabwe), a Sub-Saharan African area characterised by high HIV prevalence.ResultsFor both genders, individuals who experienced either premarital or delayed childbearing have higher HIV risk compared to individuals following more standard transitions. This can be explained by the interplay of the sequences with known HIV proximate determinants, e.g., a longer exposure to sexual activity and higher rates of premarital sex. Moreover, we found that people in the younger birth cohorts experience more normative and safer sequences.ConclusionsThe shift of younger generations towards more normative transitions to parenthood is a sign of behaviour change that might have contributed to the observed reduction in HIV prevalence in the area. On the other hand, for people with less normative transitions, targeted strategies are essential for HI
Pufall E, Eaton JW, Nyamukapa C, et al., 2016, The relationship between parental education and children's schooling in a time of economic turmoil: The case of East Zimbabwe, 2001 to 2011., International Journal of Educational Development, Vol: 51, Pages: 125-134, ISSN: 1873-4871
Using data collected from 1998 to 2011 in a general population cohort study in eastern Zimbabwe, we describe education trends and the relationship between parental education and children's schooling during the Zimbabwean economic collapse of the 2000s. During this period, the previously-rising trend in education stalled, with girls suffering disproportionately; however, female enrolment increased as the economy began to recover. Throughout the period, children with more educated parents continued to have better outcomes such that, at the population level, an underlying increase in the proportion of children with more educated parents may have helped to maintain the upwards education trend.
Bórquez A, Cori A, Pufall EL, et al., 2016, The Incidence Patterns Model to Estimate the Distribution of New HIV Infections in Sub-Saharan Africa: Development and Validation of a Mathematical Model., PLOS Medicine, Vol: 13, ISSN: 1549-1277
BACKGROUND: Programmatic planning in HIV requires estimates of the distribution of new HIV infections according to identifiable characteristics of individuals. In sub-Saharan Africa, robust routine data sources and historical epidemiological observations are available to inform and validate such estimates. METHODS AND FINDINGS: We developed a predictive model, the Incidence Patterns Model (IPM), representing populations according to factors that have been demonstrated to be strongly associated with HIV acquisition risk: gender, marital/sexual activity status, geographic location, "key populations" based on risk behaviours (sex work, injecting drug use, and male-to-male sex), HIV and ART status within married or cohabiting unions, and circumcision status. The IPM estimates the distribution of new infections acquired by group based on these factors within a Bayesian framework accounting for regional prior information on demographic and epidemiological characteristics from trials or observational studies. We validated and trained the model against direct observations of HIV incidence by group in seven rounds of cohort data from four studies ("sites") conducted in Manicaland, Zimbabwe; Rakai, Uganda; Karonga, Malawi; and Kisesa, Tanzania. The IPM performed well, with the projections' credible intervals for the proportion of new infections per group overlapping the data's confidence intervals for all groups in all rounds of data. In terms of geographical distribution, the projections' credible intervals overlapped the confidence intervals for four out of seven rounds, which were used as proxies for administrative divisions in a country. We assessed model performance after internal training (within one site) and external training (between sites) by comparing mean posterior log-likelihoods and used the best model to estimate the distribution of HIV incidence in six countries (Gabon, Kenya, Malawi, Rwanda, Swaziland, and Zambia) in the region. We subsequ
Yeatman S, Eaton JW, Beckles Z, et al., 2016, Impact of ART on the Fertility of HIV-Positive Women in Sub-Saharan Africa, Tropical Medicine & International Health, Vol: 21, Pages: 1071-1085, ISSN: 1365-3156
ObjectiveUnderstanding the fertility of HIV-positive women is critical to estimating HIV epidemic trends from surveillance data and planning resource needs and coverage of prevention-of-mother-to-child transmission services in sub-Saharan Africa. In light of the considerable scale-up in antiretroviral therapy (ART) coverage over the last decade, we conducted a systematic review of the impact of ART on the fertility outcomes of HIV-positive women.MethodsWe searched Medline, Embase, Popline, PubMed and African Index Medicus. Studies were included if they were conducted in sub-Saharan Africa and provided estimates of fertility outcomes (live births or pregnancies) among women on ART relative to a comparison group.ResultsOf 2070 unique references, 18 published papers met all eligibility criteria. Comparisons fell into four categories: fertility of HIV-positive women relative to HIV-negative women; fertility of HIV-positive women on ART compared to those not yet on ART; fertility differences by duration on ART; and temporal trends in fertility among HIV-positive women. Evidence indicates that fertility increases after approximately the first year on ART, and that while the fertility deficit of HIV-positive women is shrinking, their fertility remains below that of HIV-negative women. These findings, however, were based on limited data mostly during the period 2005-2010 when ART scaled up.ConclusionsExisting data are insufficient to characterize how ART has affected the fertility of HIV-positive women in sub-Saharan Africa. Improving evidence about fertility among women on ART is an urgent priority for planning HIV resource needs and understanding HIV epidemic trends. Alternative data sources such as antenatal clinic data, general population cohorts and population-based surveys can be harnessed to understand the issue.
Garnett GP, Hallett TB, Takaruza A, et al., 2016, Providing a conceptual framework for HIV prevention cascades and assessing feasibility of empirical measurement with data from east Zimbabwe: a case study, Lancet HIV, Vol: 3, Pages: E297-E306, ISSN: 2352-3018
BackgroundThe HIV treatment cascade illustrates the steps required for successful treatment and is a powerful advocacy and monitoring tool. Similar cascades for people susceptible to infection could improve HIV prevention programming. We aim to show the feasibility of using cascade models to monitor prevention programmes.MethodsConceptual prevention cascades are described taking intervention-centric and client-centric perspectives to look at supply, demand, and efficacy of interventions. Data from two rounds of a population-based study in east Zimbabwe are used to derive the values of steps for cascades for voluntary medical male circumcision (VMMC) and for partner reduction or condom use driven by HIV testing and counselling (HTC).FindingsIn 2009 to 2011 the availability of circumcision services was negligible, but by 2012 to 2013 about a third of the population had access. However, where it was available only 12% of eligible men sought to be circumcised leading to an increase in circumcision prevalence from 3·1% to 6·9%. Of uninfected men, 85·3% did not perceive themselves to be at risk of acquiring HIV. The proportions of men and women tested for HIV increased from 27·5% to 56·6% and from 61·1% to 79·6%, respectively, with 30·4% of men tested self-reporting reduced sexual partner numbers and 12·8% reporting increased condom use.InterpretationPrevention cascades can be populated to inform HIV prevention programmes. In eastern Zimbabwe programmes need to provide greater access to circumcision services and the design and implementation of associated demand creation activities. Whereas, HTC services need to consider how to increase reductions in partner numbers or increased condom use or should not be considered as contributing to prevention services for the HIV-negative adults.
Reniers G, Wamukoya M, Urassa M, et al., 2016, Data resource profile: network for analysing longitudinal population-based HIV/AIDS data on Africa (ALPHA Network), International Journal of Epidemiology, Vol: 45, Pages: 83-93, ISSN: 1464-3685
The Network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA Network, http://alpha.lshtm.ac.uk/) brings together ten population-based HIV surveillance sites in eastern and southern Africa, and is coordinated by the London School of Hygiene and TropicalMedicine (LSHTM). It was established in 2005 and aims to (i) broaden the evidence base on HIV epidemiology for informing policy, (ii) strengthen the analytical capacity for HIV research, and (iii) foster collaboration between network members. All study sites, some starting in the late 1980s andearly 1990s, conduct demographic surveillance in populations that range from approximately 20 to 220 thousand individuals. In addition, they conduct population-based surveys with HIV testing, and verbal autopsy interviews with relatives of deceased residents. ALPHA Network datasets have beenused for studying HIV incidence, sexual behaviour and the effects of HIV on mortality, fertility, and household composition. One of the network’s substantive focus areas is the monitoring of AIDS mortality and HIV services coverage in the era of antiretroviral therapy. Service use data areretrospectively recorded in interviews and supplemented by information from record linkage with medical facilities in the surveillance areas. Data access is at the discretion of each of the participating sites, but can be coordinated by the network.
Gregson S, Fenton R, Nyamukapa C, et al., 2016, Wealth Differentials in the Impact of Conditional and Unconditional Cash Transfers on Education: Findings from a Community-Randomised Controlled Trial in Zimbabwe, Psychology, Health & Medicine, Vol: 21, Pages: 909-917, ISSN: 1354-8506
We investigated (1) how household wealth affected the relationshipbetween conditional cash transfers (CCT) and unconditional cashtransfers (UCT) and school attendance, (2) whether CCT and UCTaffected educational outcomes (repeating a year of school), (3) ifbaseline school attendance and transfer conditions affected howmuch of the transfers participants spent on education and (4) if CCTor UCT reduced child labour in recipient households. Data wereanalysed from a cluster-randomized controlled trial of CCT and UCTin 4043 households from 2009 to 2010. Recipient households received$18 dollars per month plus $4 per child. CCT were conditioned onabove 80% school attendance, a full vaccination record and a birthcertificate. In the poorest quintile, the odds ratio of above 80% schoolattendance at follow-up for those with below 80% school attendanceat baseline was 1.06 (p = .67) for UCT vs. CCT. UCT recipients reportedspending slightly more (46.1% (45.4–46.7)) of the transfer on schoolexpenses than did CCT recipients (44.8% (44.1–45.5)). Amongstthose with baseline school attendance of below 80%, there was nostatistically significant difference between CCT and UCT participantsin the proportion of the transfer spent on school expenses (p = .63).Amongst those with above 80% baseline school attendance, CCTparticipants spent 3.5% less (p = .001) on school expenses than UCTparticipants. UCT participants were no less likely than those in thecontrol group to repeat a grade of school. CCT participants had .69(.60–.79) lower odds vs. control of repeating the previous schoolgrade. Children in CCT recipient households spent an average of .31fewer hours in paid work than those in the control group (p < .001)and children in the UCT arm spent an average of .15 fewer hours inpaid work each week than those in the control arm (p = .06).
Campbell C, Andersen L, Mutsikiwa A, et al., 2016, Can Schools Support HIV/AIDS-Affected Children? Exploring the 'Ethic of Care' amongst Rural Zimbabwean Teachers, PLOS One, Vol: 11, ISSN: 1932-6203
How realistic is the international policy emphasis on schools ‘substituting for families’ ofHIV/AIDS-affected children? We explore the ethic of care in Zimbabwean schools to highlightthe poor fit between the western caring schools literature and daily realities of schoolsin different material and cultural contexts. Interviews and focus groups were conducted with44 teachers and 55 community members, analysed in light of a companion study of HIV/AIDS-affected pupils’ own accounts of their care-related experiences. We conceptualiseschools as spaces of engagement between groups with diverse needs and interests (teachers,pupils and surrounding community members), with attention to the pathways throughwhich extreme adversity impacts on those institutional contexts and social identificationscentral to giving and receiving care. Whilst teachers were aware of how they might supportchildren, they seldom put these ideas into action. Multiple factors undermined caringteacher-pupil relationships in wider contexts of poverty and political uncertainty: loss ofmorale from low salaries and falling professional status; the inability of teachers to solveHIV/AIDS-related problems in their own lives; the role of stigma in deterring HIV/AIDSaffectedchildren from disclosing their situations to teachers; authoritarian teacher-learnerrelations and harsh punishments fuelling pupil fear of teachers; and lack of trust in the widercommunity. These factors undermined: teacher confidence in their skills and capacity tosupport affected pupils and motivation to help children with complex problems; solidarityand common purpose amongst teachers, and between teachers and affected children; andeffective bridging alliances between schools and their surrounding communities–all hallmarksof HIV-competent communities. We caution against ambitious policy expansions ofteachers' roles without recognition of the personal and social costs of emotional labour, andthe need for significant i
Skovdal M, Campbell C, Mupambireyi Z, et al., 2016, Unpacking 'OVC': Locally Perceived Differences Between Orphaned, HIV-Positive and AIDS-Affected Children in Zimbabwe, CHILDREN AND YOUNG PEOPLE LIVING WITH HIV/AIDS: A CROSS-CULTURAL PERSPECTIVE, Editors: Liamputtong, Publisher: SPRINGER INTERNATIONAL PUBLISHING AG, Pages: 23-42, ISBN: 978-3-319-29934-1
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Coultas C, Broaddus E, Campbell C, et al., 2015, Implications of Teacher Life–Work Histories for Conceptualisations of 'Care': Narratives from Rural Zimbabwe, Journal of Community & Applied Social Psychology, Vol: 26, Pages: 323-339, ISSN: 1099-1298
Schools are increasingly seen as key sites for support to HIV-affected and other vulnerable children, and teachers are assigned the critical role of identifying and providing psychosocial support. Drawing on the life-work history narratives of 12 teachers in Zimbabwe, this paper explores the psychosocial processes underpinning teachers' conceptualisations of these caring roles. The influence of prolonged adversity, formative relationships, and broader patterns of social and institutional change in teacher identity formation processes speak to the complex and embodied nature of understandings of 'care'. In such extreme settings teachers prioritise the material and disciplinary aspects of 'care' that they see as essential for supporting children to overcome hardship. This focus not only means that emotional support as envisaged in international policy is commonly overlooked, but also exposes a wider ideological clash about childrearing. This tension together with an overall ambivalence surrounding teacher identities puts further strain on teacher-student relationships. We propose the current trainings on providing emotional support are insufficient and that more active focus needs to be directed at support to teachers in relation with their students. © 2015 The Authors. Journal of Community & Applied Social Psychology published by John Wiley & Sons Ltd.
Gregson S, LeRoux-Rutledge E, Guerlain M, et al., 2015, It’s harder for boys? Children’s representations of their HIV/AIDS-affected peers in Zimbabwe, AIDS Care, ISSN: 0954-0121
Gregson S, Schur N, Mylne A, et al., 2015, The effects of household wealth on HIV prevalence in Manicaland, Zimbabwe - a prospective household census and population-based open cohort study, Journal of the International AIDS Society, Vol: 18, ISSN: 1758-2652
Introduction: Intensified poverty arising from economic decline and crisis may have contributed to reductions in HIV prevalencein Zimbabwe.Objectives: To assess the impact of the economic decline on household wealth and prevalent HIV infection using data from apopulation-based open cohort.Methods: Household wealth was estimated using data from a prospective household census in Manicaland Province (1998 to2011). Temporal trends in summed asset ownership indices for sellable, non-sellable and all assets combined were compared forhouseholds in four socio-economic strata (small towns, agricultural estates, roadside settlements and subsistence farmingareas). Multivariate logistic random-effects models were used to measure differences in individual-level associations betweenprevalent HIV infection and place of residence, absolute wealth group and occupation.Results: Household mean asset scores remained similar at around 0.37 (on a scale of 0 to 1) up to 2007 but decreased to below0.35 thereafter. Sellable assets fell substantially from 2004 while non-sellable assets continued increasing until 2008. Small-townhouseholds had the highest wealth scores but the gap to other locations decreased over time, especially for sellable assets.Concurrently, adult HIV prevalence fell from 22.3 to 14.3%. HIV prevalence was highest in better-off locations (small towns) butdiffered little by household wealth or occupation. Initially, HIV prevalence was elevated in women from poorer households andlower in men in professional occupations. However, most recently (2009 to 2011), men and women in the poorest householdshad lower HIV prevalence and men in professional occupations had similar prevalence to unemployed men.Conclusions: The economic crisis drove more households into extreme poverty. However, HIV prevalence fell in all socio-economiclocations and sub-groups, and there was limited evidence that increased poverty contributed to HIV prevalence decline.
Campbell C, Scott K, Skovdal M, et al., 2015, A good patient? How notions of ‘a good patient’ affectpatient-nurse relationships and ART adherence inZimbabwe, BMC Infectious Diseases, Vol: 15, ISSN: 1471-2334
Background: While patient-provider interactions are commonly understood as mutuallyconstructed relationships, the role of patient behaviour, participation in interactions, andcharacteristics, particularly ideals surrounding notions of ‘good’ and ‘bad’ patients, are underexamined.This article examines social representations of ‘a good patient’ and how theserepresentations affect patient-healthcare provider relationships and antiretroviral treatment (ART)for people living with HIV.Methods: Using thematic network analysis, we examined interview and focus group transcriptsinvolving 25 healthcare staff, 48 ART users, and 31 carers of HIV positive children, as well asfield notes from over 100 hours of ethnographic observation at health centres in rural Zimbabwe.Results: Characteristics of a good patient include obedience, patience, politeness, listening,enthusiasm for treatment, intelligence, physical cleanliness, honesty, gratitude and lifestyleadaptations (taking pills correctly and coming to the clinic when told). Many patients seek toperform within the confines of the ‘good patient persona’ to access good care and ensurecontinued access to ART; in this way, the notion of a ‘good ART patient’ can have positiveeffects on patient health outcomes. However, for people not conforming to the norms of the‘good patient persona’, the productive and health-enabling patient-nurse relationship may breakdown and be detrimental to the patient.Conclusion: We conclude that policy makers need to take heed of the social representations thatgovern patient-nurse relationships and their role in facilitating or undermining ART adherence.
Gregson S, Dharmayat K, Pereboom M, et al., 2015, Do HIV prevalence trends in antenatal clinic surveillance represent trends in the general population in the antiretroviral therapy era? The case of Manicaland, East Zimbabwe, AIDS, Vol: 29, Pages: 1845-1853, ISSN: 0269-9370
Objective: National estimates of HIV trends in generalized epidemics rely on HIV prevalence data from antenatal clinic (ANC) surveillance. We investigate whether HIV prevalence trends in ANC data reflect trends in men and women in the general population during the scale-up of antiretroviral therapy (ART) in Manicaland, Zimbabwe.Methods: Trends in HIV prevalence in local ANC attendees and adults aged 15–49 years in towns, agricultural estates, and villages were compared using five rounds of parallel ANC (N = 1200) and general-population surveys (N = 10 000) and multivariable log-linear regression. Changes in the age pattern of HIV prevalence and the age distribution of ANC attendees were compared with those in the general population. Age-specific pregnancy prevalence rates were compared by HIV infection and ART status.Results: Cumulatively, from 1998–2000 to 2009–2011, HIV prevalence fell by 60.0% (95% confidence interval, 51.1–67.3%) in ANC surveillance data and by 34.3% (30.8–37.7%) in the general population. Most of the difference arose following the introduction of ART (2006–2011). The estates and villages reflected this overall pattern but HIV prevalence in the towns was lower at local ANCs than in the general population, largely because of attendance by pregnant women from outlying (lower prevalence) areas. The ageing of people living with HIV in the general population (52.4% aged >35 years, 2009–2011) was under-represented in the ANC data (12.6%) because of lower fertility in older and HIV-infected women.Conclusion: After the introduction of ART in Manicaland, HIV prevalence declined more steeply in ANC surveillance data than in the general population. Models used for HIV estimates must reflect this change in bias.
Borquez A, Cori A, Pufall E, et al., 2015, ESTIMATING THE DISTRIBUTION OF NEW HIV INFECTIONS BY KEY DETERMINANTS IN GENERALISED EPIDEMICS OF SUB-SAHARAN AFRICA USING A VALIDATED MATHEMATICAL MODEL, Publisher: BMJ PUBLISHING GROUP, Pages: A215-A216, ISSN: 1368-4973
Pufall EL, Nyamukapa C, Robertson L, et al., 2015, Migration as a risk factor for school dropout amongst children made vulnerable by HIV/AIDS: a prospective study in eastern Zimbabwe., Vulnerable Children and Youth Studies, Vol: 10, Pages: 179-191, ISSN: 1745-0136
Orphans and other children made vulnerable by HIV in sub-Saharan Africa are at increased risk of moving household and of dropping out of school. However, the relationship between child migration and school enrolment has not been established. Multivariable regression models and prospective data from a cohort of children in Manicaland, Zimbabwe, were used to investigate the effect of migration on school enrolment. Children who had moved household were at increased risk of dropping out of school after adjusting for orphan status, relationship to primary caregiver, and household wealth. Interventions are needed to ensure that children who migrate are re-enrolled in school.
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